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The Last 5 Years
A Review of Maternal Critical Care Admissions in Edinburgh
Oliver Robinson ST6 ICU Trainee
Arlene Wise Consultant Anaesthetist
l The physiological function of reproductioncarries with it a number of possible outcomesincluding grave risks of death and disability forthe mother and her baby
WHO, Maternal Death Surveillance and Response, 2013
Providing equity of critical andmaternity care for the critically illpregnant or recently pregnant women
QuickTime™ and a decompressor
are needed to see this picture.
Previous National Obstetric Audits
l UK Confidential Maternal Death Enquiriesl CEMACH, CMACE, MBRACE
l CMACE (2011)l Highlighted need for improved specialist care in the
management of critically ill obstetric patients
Maternal Mortality
l 287,000 maternal deaths per year world wide
l 99% of these in developing world
WHO, Maternal mortality, 2012
Maternal Mortality
l Londonl The Lancet (2012): Rising Maternal Deathsl Higher death rate when compared with rest of UK
l Also rising in Austria, Canada, Denmark, Netherlands, Norway, USA
Relevance of Obstetric Critical Care
l Account for a small but clinically significant percentage of ICU admissions
l Rising birth rate
l Generally young patients with good pre-morbid state
l A increasing subgroup of obstetric patients with complex medical conditions
Scottish Obstetric ICU Patients
l How many obstetric patients admitted to ICU in Scotland?
l What resources do they require?
l What about WardWatcher?
Intensive Care National Audit and Research Centre (ICNARC)
l Case mix programme 2009-2012l England, Northern Ireland and Walesl 2.9 obstetric critical care patients per 1000
deliveries
l Safer child birth (2007)l Estimated rate at 1 per 1000 deliveries
ICNARC 2009-2012
6920 ICU maternity patients
1,220 currently pregnant (18%)
5,700 recently pregnant(82%)
9% Obstetric
91% Non Obstetric
70% Obstetric
30% Non Obstetric
The Reviewl Purposel Provide a Scottish perspective
l Identifyl Trendsl Risk factors for ICU admissionl Work loadl Level of care required
l To help justify further development and training
The Review
l 1st January 2009 to 31st December 2013
l Identifying obstetric patients on WardWatcher was challenging!!!
The Review
l All Obstetric patients admitted to ICUl From start of pregnancy to 6 weeks postnatall Data collected includedl Age, apache, length of stay, BMI, level of care,
ethnicity, parity, delivery method, maternal outcome, fetal outcome, medical co-morbidities and many more
l All normal births examined - 34,631 birthsl Age, BMI, parity, ethnicity
Results (2009- 2013)
5721 ICU Admissions
110 (1.92%) obstetric patients
32 patients Level 2 (29%)
78 patients Level 3 (71%)
Level 3 Patients
78 patients (71%)
63 Ventilated(80.7%)
2 Ventilation, Vasopressors + CVVH (2.7%)
13 Ventilation + Vasopressors
(16.6%)
Reason for admission
110 Patients admitted to RIE ICU
13 currently pregnant (14%)
97 recently pregnant(86%)
0% Obstetric
100% Non Obstetric
84% Obstetric
16% Non Obstetric
Birth Rate and Obstetric ICU Admission Rate - RIE
58546067 6168
6508
69536704
6981 7006 70536887
1.37
2.47
2.76
2.46
2.88
3.133.01
3.28
3.68
2.76
0
1000
2000
3000
4000
5000
6000
7000
8000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
YEAR
0
0.5
1
1.5
2
2.5
3
3.5
4
Crit
ical
car
e ad
mis
sion
per
th
ousa
nd d
eliv
erie
s
Deliveries peryear
MaternalCritical Careadmissionsper year
Trendsl Comparing 2 periods 2004-2008 vs 2009-
2013:
l 9.6% increase in birth rate
l 67% increase in maternal critical care admissions
l Statistically significant increase in maternal critical care admissions p<0.05 taking into account the increasing birth rate between the 2 periods
Admission Rate
Category Critical care admissions
RIE ICU maternity patients 3.18 per 1000 deliveries
ICNARC (England, Wales and Northern Ireland)
2.90 per 1000 deliveries
RIE ICU maternity patients (excluding tertiary referrals)
2.74 per 1000 deliveries
Mortality Reviewl Maternal mortality rate (UK)l 11.39 per 100,000 maternities
l Maternal mortality rate (RIE)l 4 deaths out of 34,631 maternitiesl Extrapolated 11.55 per 100,000 maternitiesl Lung cancerl Subarachnoid haemorrhagel Pneumococcal meningitisl VF arrest - secondary to peri-partum cardiomyopathy
Dx - Most common
1. Haemorrhage 41.7%2. Pneumonia 10.2%3. Decompensation congenital heart 7.4%4. Peri-partum cardiomyopathy 5.4%5. Pre-eclampsia 3.7%6. Eclampsia 2.8%7. Chorioamnionitis 2.8%8. H1N1 2.8%
Dx - Rare but interesting
Posterior reversible encephalopathy (PRESS) 2 cases
HELLP Syndrome 1 caseAmniotic fluid embolism 1 caseUterine rupture 1 caseAortic dissection 1 caseSpontaneous cervical epidural haematoma 1 caseLung cancer 1 case
BMI
l Range 17.2 - 81kg/m2 (median 25.5kg/m2)
l BMI for 110 ICU patients compared with BMI of the 34,631 normal deliveries
l BMI >30kg/m2 at booking = risk of ICU admission (p<0.05)
Age
l Range 16-48 (Median 32)
l Age for 110 ICU patients compared with Age of the 34,631 normal deliveries
l Age > 35 = risk of admission to ICU (p<0.05)
Results
l Total blood loss (haemorrhage as primary diagnosis)l Range 3-25 Litres (median 6.6)
l Length of stayl Range 0.2-35.4 days (median 1.2)l 35% stayed longer than 48 hours
Utilisation of Obstetric HDU
l All HDU admissions over an 8 week periodl 115 patients l 90% postnatal -> 63% PPHl 10% antenatal -> 66% Diabetes Mellitus
l Extrapolated to a year = 750 patients
l Support, develop and utilise
Extrapolating of data Scotland wide
l 2.74 admissions per 1000 births in RIE
l 58,000 births in Scotland 2011-2012
l Therefore estimated… 159 Obstetric ICU patients per year in Scotland
Summaryl Rising critical care admission rate disproportionate to
rising birth rate
l No increase in ICU capacity within our unit
l Obstetric critical care admission rate in RIE in line with established ICNARC admission ratesl 2.74 vs 2.9 per 1000 maternities
l Risk factors for ICU admissionl BMI >30 or Age >35
Conclusionl Further support and development of Obstetric HDU
required to ensure that finite critical care resources are utilised in the most effective manner
l All Obstetric patients now easily identifiable on WardWatcher - Scotland wide data available next year!
l Obstetric HDU’s will start submitting also
l Through robust audit and analysis of future data we can improve care, share knowledge and plan for the future within the field of maternal critical care
lThanks for listening
lAny Questions?
